EAQ 3

The nurse is assessing four different clients. Which client is at risk of pleuritis?

Client D: Pleural friction rub (Sound) Over anterior lateral lung field (Site)

A nurse is performing physical assessment of four female clients who came for a general checkup. Which client is most at risk of developing breast cancer? age, family history of breast cancer, children, age of menopause

60, yes, none, 50

A nursing student under the supervision of a registered nurse is performing a pulse assessment. While preparing to assess the client, the registered nurse asks the nursing student to check the apical pulse after assessing the radial pulse. What could be the reason behind for this change?

The client may have a dysrhythmia

Which client is likely to have a health promotion nursing diagnosis?

The client who is willing to take a 30 minute walk daily

Which related factor is appropriate for a nursing diagnosis?

Trauma of incision

Which anatomic area is palpated if the nurse suspects aortic abnormalities?

Epigastric Area

The nurse is assessing a client who reports breathlessness. Which activity best ensures that the nurse obtains accurate and complete data to prevent a nursing diagnostic error?

Assess the client's lungs

The nurse is caring for an elderly client with dementia. Which client need should the nurse prioritize while providing care?

Safety

While assessing the nails of a client with diabetes, the nurse finds that the skin on the client's hands and feet are dry due to infection. What could be the reason for this dryness?

Cutting nails after soaking them for 10 minutes in warm water.

The nurse expects a client with an elevated temperature to exhibit what indicators of pyrexia? Select all that apply.

Flushed face Increased pulse rate

An older adult client who is receiving chemotherapy for cancer has severe nausea and vomiting and becomes dehydrated. The client is admitted to the hospital for rehydration therapy. Which nursing actions have specific gerontologic implications the nurse must consider?

Assessment of skin turgor Replacement of fluid and electrolyte Administration of antiemetic drugs

A nurse assesses the vital signs of a 50-year-old female client and documents the results. Which of the following are considered within normal range for this client?

Oral temperature 98.2° F Apical pulse 88 beats per minute and regular Blood pressure 116/78 mm Hg while in a sitting position

The nurse is performing a breast assessment. Which statement made by the client indicates the risk of breast cancer? Select all that apply.

- "My first child was born when I was 32." - "I noticed a slight discharge from a nipple." - "I consume two to four glasses of alcohol a day."

While demonstrating the method of measuring blood pressure to a student nurse, the registered nurse measures the blood pressure in a client as 130/80 mm Hg. After the demonstration, when the student nurse is measuring the blood pressure in the same client, it is found to be 120/90 mm Hg. What could be the possible reasons for this difference? Select all that apply.

-Poor fitting of the cuff-Deflating the cuff too quickly

While assessing a client's hair, a nurse notices that the client has head lice. The nurse teaches the client about hair hygiene and lice control. Which statements made by the client indicates an understanding of the teaching?

"I should use a dilute vinegar solution to loosen the nits." "I should use a shampoo treatment once every 24 hours." "I will clean my comb in ammonia water."

Which features distinguish nursing diagnoses from medical diagnoses? Select all that apply.

1. Nursing diagnoses involve the client when possible 4. Nursing diagnoses involve the sorting of health problems within the nursing domain 5. Nursing diagnoses involve clinical judgment about the client's response to health problems.

A client is admitted to the hospital after an accident. The nurse uses the Glasgow Coma Scale (GCS) with the client. The client is alert and opens his or her eyes when there is a sound or when someone talks. When questions are asked, the client answers in a confused manner. The client obeys commands, such as being asked to move a leg. What would be the client's total score? Record your answer using a whole number.

13

A registered nurse notices that a student nurse who is assessing the blood pressure in a client is deflating the cuff too rapidly. What is the probable reading of blood pressure that the student nurse could have obtained if the actual blood pressure of the client is 140/90 mm Hg?

130/100 mmHg

The findings of four clients who underwent eye examinations are given below. Which client is suspected to have sustained injury to the cranial nerve III?

Drooping eyelids

The community nurse is assessing an elderly client who lives alone at home. The nurse finds that the client refrains from physical activity for fear of falling when walking. Which interventions by the nurse are most beneficial to promote a healthy lifestyle? Select all that apply.

Encourage the client to wear nonskid shoes. Suggest that the client use an assistive device. Help the client rearrange furniture in the hous

performing a neck assessment, the nurse finds the client has enlarged lymph nodes. The client also had a history of intravenous drug use and bisexual activity. What would be the possible diagnosis?

HIV

Which diagnosis made by the nurse is helpful in providing the right nursing interventions for the client?

The nurse identifies that the client is not aware of perineal care and has impaired skin integrity.

While assessing a client's skin, a nurse notices that the skin is dry. What is the probable etiology of the condition? Select all that apply.

The use of hard soap and frequent bathing may result in dry skin.

The heartbeat assessment of four clients is given below. Which client is at an increased risk for right-sided heart failure?

client ARJVP-2.5CMLJVP-3.0CM Bilateral pressures higher than 2.5 cm are considered elevated and are a sign of right-sided heart failure. Client A has both right and left jugular venous pressure above 2.5 cm.

While assessing a pediatric client, an ophthalmologist notices that the child is unable to focus on an object with both eyes simultaneously. Which other findings in the client confirms the diagnosis as strabismus? Select all that apply.

crossed eyes appearance; impaired extraocular muscles Strabismus is a congenital condition in which both eyes do not focus on an object simultaneously, resulting in a crossed appearance of the eyes

A nurse is teaching a client about measures to promote health. Which statements made by the client indicate effective learning? Select all that apply.

"I will assess my own pulse rate after exercising." "I will follow my hypertension treatment plan consistently. "I will perform a self-assessment of my heart rate using the carotid pulse.

A registered nurse is teaching a nursing student about the third heart sound (S3). Which statement given by the nursing student indicates a need for further education?

"S3 is normal in pregnant women."

The nurse assesses a client's pulse and documents the strength of the pulse as 3+. The nurse understands that this indicates the pulse is

Full

A nurse is teaching a client about breast health promotion and prevention practices which action described by the client indicates the need for further teaching?

Increasing meat consumption

A senior high school student, whose immunization status is current, asks the school nurse which immunizations will be included in the precollege physical. Which vaccine should the nurse tell the student to expect to receive?

MMR

After recovery from a modified neck dissection for oropharyngeal cancer, the client receives external radiation to the operative site. For which most critical reaction to the radiation should the nurse assess the client?

Mucosal edema